Sports Clubs Safety Officer Registration

Safety Officer Details

Safety Officer Registrations must be typed and submitted via emailed to Nathan Avery at:(nathan.avery@csuci.edu) in its entirety no less than 14 business days prior to practice or competition.

Select your sports club:

If "Other":

Today's Date:
MM/DD/YYYY

Name of Requestor:
FirstLast

Requestor Title:

PresidentTreasurerAdvisorOther

If Other is selected, please place information in the Other field.

If "Other":

Requestor Phone:
###-###-####

Requestor's Dolphin Email:

ADVISOR'S INFORMATION

Name of Advisor:
FirstLast

Advisor's Phone:
###-###-####

Advisor's Dolphin Email:

Certificates Obtained

Type of requested report:

CPRFirst AidEMTAthletic TrainerOther

If Other is selected, please place information in the Other field.

If "Other":

Please copy and attach a File:

CONFIRMATION

By signing below, I agree to read the Sports Clubs Handbook and enforce all Campus Recreation procedures and University policies as outlined in the Student Code of Conduct. I agree to inform the Recreation Sports when any Certificate information has expired.